Notification of Changes for Business Entity
General Information
Business Entity Name:	ELLSWORTH CORPORATION
Incorporation / Formation Date:
FEIN:	72-1400154
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	LA
County:	JEFFERSON
Business Address
Address 1:	3636 S. I-10 SERVICE ROAD
Address 2:
City:	METAIRIE
State:	LA
Zip:	70001
Phone:	504-455-4545
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	P.O. BOX 8210
Address 2:
City:	METAIRIE
State:	LA
Zip:	70011
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
ALEXANDER JOHN ELLSWORTH	PRESIDENT	3732660	YES		10/11/2017
STEVEN MICHAEL BARONE	CHIEF OPERATING OFFICER	635683		YES	10/11/2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	KATHRYN MOORE
Title:	CHIEF FINANCIAL OFFICER
Phone Number:	504-455-4545
Email Address:	KATHYM@ELLSWORTHCORPORATION.COM